Another Good Job

For the second time in two weeks I did a job where we did some actual good. To be completely honest it put my crewmate and I on a bit of a buzz for the rest of the day.
The job stated out as a bog standard chest pain; 41 year old male, pain in the chest radiating down his left arm. He is originally from the Indian sub-continent and people from this part of the world tend to have a lot of heart problems.

It didn't seem like a big job to be honest, he didn't look like he was having a heart attack – he wasn't sweaty, the pain got worse when he breathed in (often a sign of non-cardiac chest pain), he didn't have the 'feeling of impending doom' that is described daily in ambulance training schools across the world.

But he just didn't look right. I have no idea what it was about him, but there was something about him that set alarm bells ringing.

So we popped him onto our carry chair and wheeled him out to the ambulance in order to do a few checks before taking him to hospital.

His blood pressure was high, but everything else seemed fine. As we were preparing to do an ECG (a tracing of what is going on in the heart) my crewmate and I agreed that no matter what it showed we would be 'blueing' him into the local hospital, just based on the feeling we had about the patient.

His ECG printed out and we realised that we wouldn't be going to the nearest hospital around 400 yards away.

There is something that the LAS do exceptionally well, and that is to diagnose heart attacks (properly called Myocardial Infarctions, or MI's). We have good experience of spotting ST segment elevation MI's and dealing with them accordingly. Not so long ago the treatment for an MI was to have a 'clotbusting' drug which worked most of the time and has the possibility of some serious side effects (like bleeding onto the brain and death). Recently, in London at least, some specialist hospitals have been offering 'primary angioplasty' which is a surgical proceedure where a wire is threaded from your groin into your heart and the blockage is cleared manually. It's done under a local anaesthetic and is the gold standard treatment.

So now the LAS will diagnose a heart attack and instead of taking you to the nearest hospital for sub-standard treatment, will take you to the specialist unit for the best treatment possible.

This patient was having a massive MI. Absolutely life-threatening.

He had been waiting for a same day appointment to see his GP about the pain, but as the pain got worse he'd wisely called for an ambulance.

We gave him aspirin, morphine and GTN – good, immediate treatment for his MI, and blued him to the specialist unit.

As we arrived we showed the receiving doctor the ECG heart trace. He told us that, “That's all I need to see, bring him straight through”. We moved him onto the hospital's trolley and left him in the care of the doctors while they assessed him for surgery.

Then his heart stopped pumping blood.

He was dead.

Rapid, effective treatment by the doctors restarted his heart within a minute and he was soon asking them if he had just fainted. During this I was explaining to the wife what was happening. English wasn't her first language so she was confused by what was going on.

He was rushed into the surgery room and the doctors asked if we would like to see the proceedure – as we were doing our paperwork we agreed.

An x-ray image of his heart came on the screen as they pumped a contrast agent into his blood to show where the blockage was.

There are two main arteries feeding blood to the heart, one branch of these was completely blocked. The doctor described it as 'The widowmaker'; a severe blockage in exactly the wrong place. This was almost certainly why his heart had stopped beating effectively while they were preparing him for surgery.

We watched as they did a bit of delicate plumbing work to remove the blockage and restored the flow of blood to his heart.

While he will almost certainly survive this episode, I wonder what damage has been done to his heart; the MI causes part of the heart to become starved of oxygen and this can reduce it's function.

If he'd waited the hour to go and see the GP, he would be dead.

If he hadn't called for an ambulance, he'd be dead.

If we weren't routinely trained to recognise MI's and take them to the right place, he'd be dead.

If the primary angioplasty wasn't available, he'd probably be dead.

Everything went right on this call, we felt that we had saved his life (a rarity in this job), and it let us feel that we had earned our pay today.

Another 'good' job.

And our next two jobs were picking up unkempt homeless drunks from the street. It doesn't do to get an ego in this job…

For the medically minded, he had a VF/VT arrest, corrected after two shocks and a complete blockage of the LAD about 3mm from the base.

Neat! Though I've had a feeling of impending doom ever since I was old enough to understand television news….Love that the Dynorod approach trumps pharmaceuticals in these cases too. The one criticism I have is that the line “He was dead” is maybe a bit inaccurate, it's more that he took a short-haul break to Dead, then returned in time for supper.

I don't know why it's happens, but all of the training manuals state that a patient who is having a heart attack will instinctively feel that they're about to die.But nobody has been able to tell me *why* you get this response. Any ideas folks?

Got to say, I've never felt inclined to say “So, do you feel like you're about to die?” to a ?MI. I interpret it as being when the patient is saying “I'm dying…I'm dying”…their body knows something pretty major is going on!Good on you Tom – great result!

Our areas do the same now and I must say that this new system works wonders, I too had a similar job a few days ago when on the FRV, although I unfortunately didn't get the opportunity to follow it through as you did, its such a brilliant system to be able to bypass the nearest A&E and get them to a specialist department who can sort out the problem immediately. We started it as a trial last year and now follow the procedure as a matter of course. Its an amazing thing to watch too….Well done to the both of you, special pats on the backs all round

Can someone please Define a Sense of Impending Doom lol. It cracks me up everytime I see, hear or read it. Is it true in some constabularies crews arnt allowed to use thrombolytic drugs…Hmmm seems stupid. But at 800 odd quid a pill, i guess they wanna use it sparingly.

We're about to start a similar system in the Black Country (Wolverhampton, Dudley, Walsall, etc.). As of 1/4/07 (April Fools' Day….!) any suspected STEMI will bypass (pun intended) what may be the closest A&E and be taken direct to a specialist centre offering PCI.I have a feeling that the slightly longer journey times will cause some anxiety amongst crews, but I'm sure that the benefits will outweigh the disadvantages. I hope.Just playing Devil's Advocate, Tom, how do you think you would have felt if the pt had arrested en route to the hospital with the cath lab, and hadn't recovered? I'm not doubting your defib skills in any way, but it could just happen. That's one part of the new system that worries me, I must admit: I make the decision (OK, the decision has already been made for me by the policy makers, but the diagnosis is down to me) not to transport to an A&E 2 or 3 minutes away, and instead take the extra 15 minutes to get to the cath lab. Patient arrests and dies 10 minutes into the journey. How long am I going to be dogged by “What if?” questions??Any idea if this scenario happened in LAS?

It's maybe a bit naff and newage, but wouldn't it be nice if everyone blogged (even just anonymously) one NICE thing that happened to them each week, be it this kind of thing, or just someone letting you sit down on the bus.Mine was someone letting me have the last pack of coffee on the shelf: they were ahead of me and saw me check if there was any more on the shelf, asked if I'd run out (I had), and handed me the pack they'd picked up because they were just stocking up and had plenty at home.

Just one point I'd like to argue about. You say you earned your pay, I say you earned a damn sight more than you are paid, but don't hold your breath. it doesn't look like you'll be getting any more money! Grrrr

Apparently you get the sense of impending doom with anaphylaxis, I'd be interested to know what to expect. Do people panic that they're going to die, or that the whole world's going to end or what? It's said so often, but when asked, people don't really know what it means, it's funny.

My Dad had serveral MIs before he died from a massive CVA. After his 2nd MI we were chatting in the CCU and he too told me that he had felt an 'impending sense of doom'. When I asked him what he meant, he said that he just knew that something major was about to approach him, a bit like when you are sat in a traffic jam and see a car hurtling towards you in your rear view mirror – you know it's going to hit but there is nothing you can do about it. And then this strange calm settles over you simply because it is going to happen and there's nothing you can do to stop it. I like to think that he was that calm before he died cos despite what we were told, he did know that we were there when unconscious after the CVA. He squeezed our hands when we told him that we loved him – not just Mum's but mine, my brother's and my sister's in turn.So as a post script, please don't assume someone is unable to hear you because they are unconcious.

Good job today sweet, it's heartwarming to know that you have made such a difference, not only to that man but to his family as well.

Well done, Tom!Luckily, not all ambulance calls come for deadly events.

We got called yesterday for an “ill pregnant woman” on a very trafficked road in Northeast Milan, but when we arrived on target we noticed that the 28-year-old lady was going to deliver her kid on the street…

We loaded the lady on the stretcher, closed the doors, called Control and headed towards the Hospital, a couple of miles from there. Suddenly, one minute later, the lady started to shout for pain… We stopped and had to hurry up in assisting her, until we heard the first cry of Marcus, a very healthy (Apgar score: 10) six-pound little boy. We clamped the umbilical cord, cleaned the baby and restarted our run to the hospital.

Even if it's a “dirty” and fairly unpayed job, it's however a great job!

I think that as long as the training is in place, and the crews are confident to diagnose STEMIs then it's all good.I know when we first started doing this it felt very wrong to bypass an A&E, but the feeling does pass.

As for dying in the back of the ambulance – I'd rather stand before the coroner and explain that the patient died because I followed protocol rather than dying after I ignored our protocol.

At the end of the day I believe that the protocol is 'right' and by following it I'm doing the best for my patient.

I hope this answers your question – if not then feel free to drop me a line.

When I first started my blog I tried to put stuff about people who had been nice to me – taxi drivers helping me get my shopping up the stairs, shop staff being more helpful than they really need to be – sometimes to cheer up a negative post, sometimes because it was exceptionally nice. Can't remember why I stopped, perhaps I should start again. Although quite a few of my posts since tags were introduced are tagged “niceness”, “friends”, “positive” and so on.Not sure whether it would be better to do it on our own blogs, or to have a big happy blog repository for this sort of thing as a group project – I fear having it as a group project would just be asking for trolls to try and shit all over it.